Llr fax: 803-896-4814 Financial Statement Balance Sheet a / rv / re




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LLR FAX: 803-896-4814 Financial Statement Balance Sheet A / RV / RE

New, Revision, or Reinstatement Applications - Use for Groups 1 & 2 ONLY

Renewals* - Use to renew your current Group 1, 2, 3, or 4 license

*LICENSES CANNOT BE UPGRADED WITH THIS FORM



Balance sheet of

(“DBA” Name):



     

Dated:

     

20

  

FORM #172
You do not have to use this form; however, all self-prepared financial statements must be signed and notarized. This financial balance sheet is designed for individuals, sole proprietorships, partnerships or corporations. This statement must be completed in accordance with SSARS, and include all disclosures required by the generally accepted accounting principles (GAAP). Attach any supplementary financial information to clarify your entries. If you have questions, please consult your accountant or CPA. The Contractors’ Licensing Board cannot answer questions pertaining to financial statements.


ASSETS




LIABILITIES

CURRENT ASSETS

Dollars

Cents




CURRENT LIABILITIES (due within 12 months)

Dollars

Cents

Cash on hand (total amount of $500 or more must be










Accounts payable

     

     

verified on a notarized statement)

     

     




Material suppliers

     

     

Cash in bank

     

     




Subcontractors

     

     

Marketable Securities (attach list)

     

     




Others

     

     

Contracts receivable (less allowance for doubtful










Taxes payable

     

     

collection):










Withheld and accrued payroll taxes

     

     

Billed (exclude claims not approved for payment):










Delinquent payroll taxes and related charges

     

     

Completed contract(s)

     

     




Other taxes (attach list)

     

     

Retainage

     

     




Income taxes payable

     

     

Unbilled

     

     




Current and deferred

     

     

Other accounts receivable (attach list)

     

     




Delinquent and related charges

     

     

Notes receivable (principal due during next 12-month










Notes payable (principal due during next 12-month period):







period) (attach list)

     

     




Speculative building construction loan

     

     

Inventory:










Real estate

     

     

Speculative Building Costs to date

     

     




Auto, trucks and equipment

     

     

Materials in stock (verify any amount in excess










Material purchases

     

     

of $10,000

     

     




Loans on insurance cash value

     

     

Other inventory (attach list)

     

     




Other (attach list)

     

     

TOTAL CURRENT ASSETS

     

     




Interest in arrearage

     

     

FIXED AND OTHER ASSETS:










Other current liabilities (attach list)

     

     

For Individuals:










TOTAL CURRENT LIABILITIES

     

     

Real Property:










LONG TERM LIABILITIES:







Personal residence

     

     




Notes payable – long term portion (principal portion only):







Held for investment

     

     




Real estate

     

     

Other real estate property (attach list)

     

     




Autos, trucks and equipment

     

     

Personal Property

     

     




Other (attach list)

     

     

For Businesses:










Other long term liabilities (attach list)

     

     

Real Property, at cost

     

     




TOTAL LONG TERM LIABILITIES

     

     

Business fixed assets (excluding real property)

     

     













Net of accumulated depreciation and amortization

     

     




NET WORTH (TOTAL EQUITY)

Cash surrender value of life insurance policies

     

     




For Individuals:

     

     

Other noncurrent assets (attach list)

     

     




Sole proprietors and partnerships-equity







TOTAL FIXED AND OTHER ASSETS

     

     




For Corporations:

     

     

TOTAL ASSETS

     

     




Capital stock

     

     













Treasury stock

     

     







Retained earnings

     

     

REQUIRED NOTARIZATION




TOTAL NET WORTH

Total Assets minus Total Current and Total Long Term Liabilities



     

     







TOTAL LIABILITIES + TOTAL NET WORTH =

     

     

Sworn to and Subscribed before me this day of 20


Print Name of Notary Public



Signed Name of Notary Public
My Commission expires:




AFFIDAVIT
I hereby certify this financial statement is true and accurate to the best of my knowledge.



Authorized Company Representative - Printed Name Date


Authorized Company Representative - Signature




Doc#172 Rev. 12/2011


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